For many, their concept of gout is represented by the old cartoons of an overweight wealthy man sitting in a chair with his foot bandaged and elevated. Often the person is smoking a cigar. He's the product of an over-indulgent life, and readers are supposed to laugh at the old man.
But gout, of course, is not a laughing matter to those who get it, and often gout-sufferers are women, not overweight, not smokers, and don’t have the luxury of taking time off to sit in a chair.
Gout is increasing in America and other countries with similar demographics. The prevalence of gout in the US (number of cases per 1,000 population) doubled between 1969 and 1985. Currently there are estimated to be over five million Americans with gout. (The source for these data and this discussion is Management of Gout in the Elderly, a supplement to Clinical Geriatrics, September, 2009.)
What is Gout?
Gout is a type of arthritis. It’s characterized by relatively sudden episodes of pain in a joint. Unless treated, the episodes last a week or ten days, then subside. The affected joint is red, swollen, and tender. The pain can be quite severe.
Usually only one joint is affected. Often, the affected joint is in the foot. For example, gout is clearly the most common cause of arthritis in the joint connecting the big toe to the foot, the metatarsal-phalangeal joint, a condition called podagra. (Podagra is from Greek for foot pain.)
The pain and inflammation are caused by microscopic crystals of urate (technically, monosodium urate). Normally, urate is dissolved in the blood, but under certain circumstances, it can crystallize and irritate a joint space. The irritation causes an inflammatory response, with swelling, tenderness, and pain.
Between attacks, the person may be without symptoms. However, the urate crystals can continue to cause harm in the kidneys, and many believe, in blood vessels.
Risks for Gout
A newly understood risk is metabolic syndrome. This condition is characterized by fat around the abdomen, producing an apple shape compared to pear-shaped body contour. Apple-shaped people have a waist to hip ratio 0.8 or greater. Apple-people also are likely to have insulin resistance, which is thought to make the kidney remove less urate, increasing the risk for the urate to crystallize in a joint.
It is true men are more likely to get gout, but women after menopause have substantial risk also.
Other risks:
- kidney disease
- overweight
- heart failure
- taking diuretic medications (e.g., hydrochlorothiazide, or HCTZ)
- eating lots of meat, especially red meat or liver
- eating lots of seafood (shellfish, tuna, shrimp, dark fish)
- alcohol use, especially beer
The problem from red meat and fish is felt to be due to their high purine concentration. Purine leads to urate in the blood. However, purine in vegetables such as spinach, asparagus, cauliflower, peas, and mushrooms, do not affect urate. The modern “low purine diet” does not eliminate these vegetables.
Gout May Cause Other Diseases
Urate crystals may injure the kidney, as noted. Urate may also be toxic to the cardiovascular system. Current clinical trials are testing to see if lowering urate reduces cardiovascular disease.
New Treatment Approach For Acute Attack
In the past, acute attacks were treated with indomethacin and colchicine. Today, doctors are avoiding indomethacin because of its many adverse side effects. Other drugs in the same category, NSAIDs, are often chosen as being just as effective, and less dangerous.
Colchicine is now known to be more dangerous than previously thought. Colchicine was approved by the US FDA a long time ago because it was in common use. Now, a new colchicine-derivative is approaching the market, and new data show the doses of colchicine in the past are likely too close to too high. Over 100 people have died from colchicine, according to Prescriber’s Letter (September, 2009). The new preferred dose is much lower. In many cases, colchicine is no longer used at all, relying instead on NSAIDs, according to Prescriber’s Letter.
An increasingly popular option is to use steroids, especially in patients who cannot tolerate NSAIDs or who have kidney disease.
New Drugs
Febuxastat is new drug that lowers urate, and can be given during an acute attack. Other new drugs are in the approval process.
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